Collateral Damage

Part One: CITY's violence can take hidden toll - Advocates aim to save Baltimore children from impact of violence

The first time she witnessed a student's major tantrum -- a 2-year-old hurling a toy stove filled with plastic pots and pans -- Shanikia Johnson had just started as a teacher at Little Flowers Child Development Center in West Baltimore.

She knew toddlers acted out. But the rage-filled reaction, triggered when Johnson wouldn't allow the boy to play with a toy, stunned the 22-year-old teacher. Then, time and time again, she saw other children throwing classroom furniture. Bookcases, chairs, tables -- all were flung around the room.

Some students bit classmates, leaving teeth marks on hands and cheeks; a few threatened to hurt staff members. Other children, dubbed "runners," darted out of the building and down barren city blocks, with frantic teachers on their heels. The encounters exhausted Johnson and other teachers, who began to see the children as troublemakers.

But the day care center's owner, Crystal Hardy-Flowers, urged the staff to be patient with the children, who often were like any other preschoolers -- dancing to music, playing tea party and climbing onto a teacher's lap. The former social worker understood something that her teachers did not. The kids were growing up in Upton/Druid Heights, where police chases are common and sirens wake up kids like unwelcome alarm clocks at night. Almost every day, in some way, the kids were exposed to violence.

"It's not just bad behavior. It is not just defiance," Hardy-Flowers said. "No, it is deeper than that. People just don't pick up chairs and throw them at you. Children don't just run out of the building."

Science increasingly shows that Hardy-Flowers is right. Even as shootings, stabbings and murder trials grab the spotlight, violence in Baltimore is exacting another insidious, often invisible, toll -- warping the health and development of the city's youngest residents. For every child who is shot, provoking public outrage, hundreds of others hear gunshots or see fights and stabbings in neighborhoods across the city. After the ambulances drive off and the crime scenes are cleared, many of these children are left with deep psychological wounds that can trigger physical ailments.

Studies have piled up showing that in the tangle of tough, intractable issues like poverty and drug addiction, exposure to violence is a major factor damaging children's health. The stress that fills their little bodies breeds anxiety and depression, making it hard for them to concentrate in school. In fact, research has found that such experiences hurt the development of crucial areas of their brains -- those involving attention, memory and behavior control. In the worst cases, children walk around with symptoms of post-traumatic stress disorder no different from those plaguing soldiers who have fought on the front lines.

According to one researcher who has long studied these children, nearly a third of children exposed to violence will develop PTSD. As the children age, researchers believe, the impact of violence can translate into serious health problems, including hypertension and diabetes. Some early research shows that stress may even alter their DNA.

"You hear about the shootings, but you don't hear about the aftermath," said Annette March-Grier, president of Roberta's House, a grief support center that borders on the Broadway East and Oliver neighborhoods. "It's like you're killing 10 other people when you kill one. It's just slowly."

The stakes are high for Baltimore and Maryland -- and their taxpayers. If these children are not helped, they are more likely to turn to violence themselves or need government-funded mental health services. Research shows that they're also more likely to struggle to maintain jobs and be productive members of society. Since a U.S. attorney general's report in 2012 described children's exposure to violence as a national crisis, some fields, including social work, police and health care, have begun special training for workers. There are also efforts to help schools become safe places where these children can get support.

"The science has caught up. You cannot raise a kid with high levels of trauma and violence and expect they can just bounce back," said Martha Davis, senior program officer at the Robert Wood Johnson Foundation, which has funded projects in high-crime areas to address the problem. "Now the hard work is: How do we take this information and make systems that work?"

Children at the Little Flowers Child Development Center romp on the playground. Their teachers like to get them outside in the sunshine to exercise, which helps them to focus later in the classroom.

Upton/Druid Heights, near downtown, between North Avenue and Martin Luther King Boulevard, is on the frontier of this daunting effort. There are nearly 3,000 children 18 and under in the neighborhood, and statistics show it to be one of the sickest and most dangerous in Baltimore, a place where life expectancy is nearly 10 years shorter than the citywide average. And it is here -- a historic African-American neighborhood that was once a major part of the local civil rights movement -- that a cadre of social workers, teachers, pastors and others have been testing out ways to help these kids.

Through a federal grant program called Promise Heights, the University of Maryland School of Social Work is collaborating with schools, churches and community groups. The goal of the multiyear initiative is to combat the cycle of poverty by wrapping children and families in supportive services from cradle to college. Dealing with trauma is a major focus of that work.

The University of Maryland team has embedded social workers in neighborhood schools. They make home visits and coach adults on parenting. Teachers learn that instead of asking a misbehaving child, "What's wrong with you?" they need to ask, "What happened last night?"

Said Bronwyn Mayden, the project's executive director and an assistant dean at the University of Maryland School of Social Work: "The way we look at it in Promise Heights, everyone is traumatized." 

Click here for a graphic examining the health of Baltimore neighborhoods. 

Death of a sister

Like many other children in Upton/Druid Heights, 10-year-old Shamira Wedlock has already been touched by violence. The fifth-grader at Samuel Coleridge-Taylor Elementary School gets nervous when she hears gunshots in the neighborhood -- or when she's outside and a nearby car slows down. She's worried someone might start shooting.

This summer, she saw two men beating someone up at the playground in her apartment complex.

"They punched him and kicked him, and he screamed, and there was blood everywhere," she recalled. Amid the assault, one of the attackers stared right at her, unnerving her. She ran and got help, but remains haunted by the incident.

The biggest blow came in March, when her 21-year-old sister was murdered. The sister was one of three people shot and killed in an apartment across from an elementary school in a nearby West Baltimore neighborhood, a case that remains unsolved.

At the funeral, Shamira was torn with emotion -- grief for her sister, and fear that the shooter might come back that day to threaten her and her family. Since then, those fears have ebbed, through the strong support of her step-grandmother, Joann Brewer, who has taught her to be cautious, but not paralyzed by fear.

Now Shamira talks easily about those incidents -- and about how much she loves her neighborhood. But she still does find herself, when she's home alone, taking out her sister's obituary and reading it, over and over.

Another neighborhood girl has harbored some of the same fears. But in her case, police and relatives requested that she not be identified -- because she witnessed a murder that has yet to be solved.

The 11-year-old was playing outside her McCulloh Homes apartment on an April evening a few years ago when gunshots rang out.

A man her family knew, 23-year-old Brandon Simms, had been eating crabs in the courtyard about 8 p.m., when another man walked up to him, pulled out a gun and shot him in the leg. As the girl and other neighbors watched from yards away, Simms tried to crawl away. The shooter fired again -- this time into Simms' head.

The girl's mother, awakened from a nap by the firecracker-like sounds, ran outside. She found her daughter in tears, crouching in the doorway and holding tightly to a younger neighbor. A teenage daughter, who was also outside, ran to a nearby playground and hid in a play tunnel. Terrified, she didn't move until she heard her mother's voice calling her.

Bullet holes remain in the sidewalk today -- and the impact on the family lingered as well.

The youngest of the four children, an 8-year-old boy, slept on the floor of his bedroom the night of the murder, fearful someone would shoot through the window. "When you were little," he asked his mother months later, "did you used to go outside, and people would be laying on the ground?"

After the murder, the 11-year-old began to struggle in class. For months, she felt crippled by fear, and at night dreamed about what she had seen.

She didn't get a look at the killer's face, so she still worries that he could be anywhere -- walking next to her on the street, or in the park -- and she wouldn't even know it.

"I never really prayed before. But that day I was praying. I didn't want him to die," the girl said recently, reading from the letter she wrote a week after the shooting to sort through her complicated feelings. Now 14, she keeps the letter on a shelf in her closet. "I was then scared to go outside in my neighborhood. I thought that whoever was shooting might have saw me and might want to come after me next."

Reminders of the murder are hard to avoid. The whole family sidesteps the spot where Simms' body once lay. And through their living room window, they can still see a memorial dedicated to him, made of sneakers, pictures and other items hanging in a tree.

The mother, who works full-time at Furman L. Templeton Preparatory Academy, worries about the dangers outside school. Since the murder, she's desperately wanted to move.

"I know no one is promised today or tomorrow," she said. "But in some places, that is even more true. I would just like to feel safe."   

Gillian Gregory, a social worker at the University of Maryland School of Social Work, listens to students during the daily rap session in a fifth-grade class at Furman Templeton Preparatory Academy.

Neighborhood in distress

The neighborhood has a storied past. For decades, it was home to a thriving African-American middle class and to prominent and politically active families such as the Mitchells and the Murphys, owners of the Afro-American newspaper. Many of the city's important churches started here, and in the 1920s, the vibrant entertainment scene along Pennsylvania Avenue drew comparisons with the Harlem Renaissance.

Today, the neighborhood is home to many committed, long-term residents and strong community organizations. Bit by bit, with lots of hard work, some blocks once lined with boarded-up homes have been transformed with rows of new townhouses. There are parks and a community garden.

Yet it's still a neighborhood in distress, one that reflects the reality for millions of children in high-crime cities like Boston, Detroit, and Newark, N.J. Upton/Druid Heights has one of the highest concentrations of poverty in Baltimore. According to the most recent comprehensive data from the city health department, homicides and non-fatal shootings were about twice the city average in 2011, and the life expectancy of residents was 63 years compared to 72 years citywide. So far this year, as the number of homicides citywide has passed the 200 mark, there have been seven shootings and five homicides, among a total of 665 crimes in the neighborhood, which covers about 170 blocks.

Many preschoolers at Little Flowers also experience violence firsthand. At least four times a week, just outside the door of her center, Hardy-Flowers said, she sees some kind of crime. One day, the staff couldn't leave because police were crouched behind the center's bus, conducting surveillance.

Three years ago, when Promise Heights social workers began their work at Furman L. Templeton and the Samuel Coleridge-Taylor, they found classic symptoms of children stressed by violence.

Students were hypervigilant and suffering from anxiety and depression. Small conflicts blew up into huge fights, and many children had a hard time concentrating. Mundane acts triggered bad memories in kids and sparked tantrums -- for example, a child would flinch at a teacher's gesturing with her hands because it looked like hitting.

These kids hear constant rumblings about violence, even if they don't witness it. Carefully maintained memorials of flowers and balloons in trees, on light poles or even in front of an elementary school can subliminally traumatize kids by reminding them of a past shooting. According to a survey at Furman Templeton, some children skip school because they're afraid to walk through the neighborhood.

"I tell people 'the boogeyman' is not an invisible thing," said Henriette Taylor, a community school coordinator with Promise Heights.

At the pediatrician's office on Division Street, Dr. Jacqueline Fulton, who has worked in the neighborhood for more than 30 years, used to treat kids for infectious diseases. Now, she says, it's mostly health problems related to societal issues.

The stressed children have worsened asthma. Some need stitches from being beaten up on the way to school. Many have Vitamin D deficiencies because they don't get enough sunlight -- there are few playgrounds, and children are either afraid to be outside, or their parents think it's safer for them to stay indoors.

Some children are so angry and emotionally numb, Fulton noted, that they never feel afraid. And it's not surprising, experts say, that in school, many of the children can't focus for more than 10 minutes.

Some efforts to improve educational outcomes for these kids may have overlooked this crucial factor, noted the University of Maryland's Mayden. For years, public schools have tried many strategies -- new curricula, more professional development for teachers, or changing a principal -- without seeing a big improvement in achievement, she said. "What we have to do, particularly in high-poverty areas, is really begin to look at and work with children and families."

Reaction in the body

The neighborhood pediatrician, Fulton, and others around the country are grappling with the reality that not only are large numbers of children in poor neighborhoods exposed to violence, but in many cases, according to research, their very biological makeup is being altered through long-lasting changes in brain anatomy and physiology.

The human body is designed to adapt to stressful situations. In dangerous moments, energy levels rise, the heart pumps faster, and the hormones adrenaline and cortisol kick in. Those changes allow people to run faster and defend themselves. When the situation calms down, the body goes back to normal. Scientists call this the "fight or flight" response.

But for kids in Upton/Druid Heights, where crime and violence are common, this system gets overloaded, because things never really calm down. A distant gunshot. A fight in the courtyard. A memorial of flowers and balloons for a homicide victim. Kids stay in a continuous state of alertness, always prepared for something dangerous to happen -- even if they don't realize it.

Elevated levels of stress hormones can reach toxic levels that have a lifetime effect on health, derailing development of the brain and leading to physical problems, according to research from Harvard University, the Stanford University School of Medicine and other institutions.

Dr. Victor G. Carrion, a Stanford professor who has studied traumatic stress in children in California, said the effect can be seen on a brain scan.

Carrion has compared the MRI brain scans of highly stressed children, including those who live amid violence, to those of healthy youngsters. They showed overall decreased brain volume in children with high cortisol levels. Key areas responsible for complex learning also were smaller. The work, among the newest findings in the field, is still in its early stages and needs more development, but some scientists consider it significant.

Researchers like Carrion believe that -- in a child who can't sit still in school, or is so agitated that he or she throws a chair -- the brain is so busy fending off stress that other key areas don't develop properly. Carrion's scans of stressed children found a smaller prefrontal cortex, the part of the brain responsible for executive functions such as attention span, planning and organizing, goal-setting and behavior control. Carrion also gave the stressed children attention and memory tests -- and the prefrontal cortex was not as active.

Other brain scan studies showed stunted growth of the hippocampus, which may inhibit a child's ability to form new memories, learn or control emotions. The symptoms were worse for kids who experienced trauma more directly, Carrion said.

"The more interpersonal it is in terms of family or someone close to you, the more it affects you," Carrion said. "It's like being close to the epicenter of the earthquake [rather than] miles away."

Other research has found that Baltimore schoolchildren exposed to violence had a hard time sleeping and regressed to bed-wetting and other behaviors they had outgrown. Some children may become moody and have angry outbursts; others may react in the opposite way, shutting down and becoming withdrawn, said Dr. Harolyn M.E. Belcher, director of research in the Family Center at the Kennedy Krieger Institute. She has been studying the effects of and treatment for violence, parental substance abuse and child maltreatment for more than 10 years.

The unwritten rules of the neighborhood may tell children it's not OK to show sadness or fear, Belcher said. Crying is seen as a weakness. Instead, children will exhibit other feelings or behaviors -- for example, they'll act angry, because that's considered acceptable. "So depression sometimes in urban neighborhoods may not look like you're sad or blue or despondent," Belcher said. "It looks like anger, overeating, irritability or problem sleeping."

All of the built-up emotions can lead to physical health problems.

Craig K. Ewart began looking at the emotional state of children in Baltimore neighborhoods during the 1980s and '90s as a professor at the Johns Hopkins Bloomberg School of Public Health. His research team interviewed more than 700 children at Baltimore Polytechnic Institute and Western, Patterson and Walbrook high schools, all in neighborhoods with violence and other social stressors that he found put some kids on constant alert and caused their blood pressure to rise.

The flight-or-fight response that elevated stress hormones also elevated heart rates in these children, said Ewart, who found the same symptoms in students in Syracuse. Being constantly vigilant to possible dangers for long periods can cause wear and tear on the heart and the blood vessels, Ewart said. He compared it to a badly tuned car engine that runs too fast, burns too much gas, overheats, and requires constant braking. Everything wears out early. In adolescents, the wear and tear of constant stress can lead to hypertension and early heart disease later.

Ewart, a psychology professor at Syracuse University, recently re-interviewed some students, who are now in their 20s and 30s, and found that many have the same problems with elevated blood pressure they did as kids.

It's hard for doctors to predict how the impact of violence will play out in the life of a particular child. Children exposed to violence exhibit a wide range of reactions and outcomes, researchers say, depending on a web of factors, including their personal characteristics, life experiences and circumstances such as poverty and family support. According to the National Child Traumatic Stress Network, a group of front-line providers, researchers and others who treat these children, the more exposure to traumatic experiences, the greater the risk for neurobiological disturbances such as impairments in memory and regulation of emotions and behavior.

One of the newest areas of medical research looks at genetics. Scientists are examining whether prolonged stress from trauma can alter DNA. Several studies of people in stressful communities have shown shorter telomeres at the ends of chromosomes. Telomeres, which act like the protective plastic tips on the ends of shoelaces, prevent DNA in chromosomes from unraveling and cells from dying. Scientists at Duke and Tulane universities, who have done the work, believe this may mean faster aging.

Other researchers say more work needs to be done.

Carol W. Greider, a Johns Hopkins University professor who shared a Nobel Prize for her work on telomeres, for example, noted that the degree of shortening was insignificant and has not been shown to have any biological effect.

But Idan Shalev, assistant professor in the department of biobehavioral health at Pennsylvania State University, who worked on one of the studies while employed at Duke, said that researchers will push ahead. The hope, he said, is that findings in this area could lead to better ways to treat victims of trauma. 

  Michelle Fleming teaches at Little Flowers Child Development Center, using cards with facial expressions to help children understand the different feelings they experience.

Intervening to help

It's sobering to realize that the experience of the sisters who witnessed the murder at McCulloh Homes is a pattern playing out for hundreds of kids. There are so many gunshot victims that military medical personnel come to the Maryland Shock Trauma Center to train before going to war.

A study from Hopkins' Bloomberg School last week found that nearly half of all children in the United States are exposed to at least one social or family experience that can lead to traumatic stress and endanger their healthy development -- such as seeing their parents divorce, seeing a parent die, witnessing or being a victim of neighborhood violence, or living with someone who abuses alcohol or drugs.

But there is hope, because if the kids get help, experts believe they have a chance to recover. Scientists understand that the brain is more resilient than once thought, so as the kids get older, and their brains develop and mature, they may adapt.

The key is to intervene early. While medications can be prescribed to help tamp down symptoms such as difficulty sleeping, anxiety and nightmares, there is no medication that can definitively treat a child's traumatic stress, according to the National Child Traumatic Stress Network. But one treatment proven to help is cognitive behavioral therapy, including stress management and relaxation skills. Therapists also work to correct untrue or distorted ideas about a traumatic incident, as children sometimes think something they did or didn't do may have caused the violence.

What scientists don't yet know is whether improvements in the behavior they see in kids getting treatment are matched by improvements in their brains, such as more activity in the prefrontal cortex, said Carrion, the Stanford medical school professor. He plans to study this issue next.

In situations like the one the Baltimore family went through, most children here and in other cities don't get help. Too often, parents think children are left to deal with the problem on their own, or there may not be resources for counseling.

But shortly after the McCulloh Homes shooting, the mother got the children counseling at their school, Furman L. Templeton. Counselors say kids will open up at their own pace; they just need an outlet. Claire Meringolo, a clinical social worker and early childhood mental health consultant, who until recently worked with Promise Heights, lets children guide her to what they want to share. She uses play therapy, such as drawing pictures, to let kids express themselves. One child told her in a session that he saw a dead body while walking home; another talked about a man who was shot in the leg.

For children who internalize a crisis, therapists say gradually reintroducing them to the trauma and teaching them to cope with it has been proved a successful treatment. Therapists gently guide the children to tell their stories and help release stored emotions. This helps restore a sense of confidence and reduces trauma-related symptoms, said Bridget Bauersfeld with the Kennedy Krieger Family Center, which counsels families who have experienced trauma.

In Upton/Druid Heights, the University of Maryland social workers -- along with school staff members and others in the community -- are developing new routines for the children. In the Little Flowers day care, for example, teachers are dimming the lights at different times to help calm the kids, or conducting some activities outside, where sunshine and fresh air may help them focus.

The Promise Heights team has also held more than 24 sessions to teach adults how to deal with traumatized children. More than three dozen teachers who work for Hardy-Flowers have had the training. Others include foster parents, child welfare workers, and Head Start administrators.

At a recent session, 12 teachers from Little Flowers sat around tables in the basement of a church on Pennsylvania Avenue. Kyla Liggett-Creel, a clinical social worker with the University of Maryland School of Social Work, challenged the class to talk about their students' behaviors and how it makes them feel.

"Sucking teeth," said one teacher. "Angry."

"Talking back by yelling," said another. "Disrespected."

"Kicking off their shoes," said a third. "Makes me want to throw their shoes in the trash."

Liggett-Creel told the teachers it's OK to feel frustrated. But they needed to consider that something in the children's lives might be causing them to act out.

"If you're having those thoughts, then the child is never going to ... get better," she said. "Stop and say, 'This child may be traumatized. My job is to stay calm and help him learn.' "

After the weeklong session, the teachers saw the children from a new perspective. "I just thought the kids were bad," said Johnson, one of the teachers. "Now, I take a step back and think about whether something happened that maybe the student isn't telling me."

On a day after the training, some children were sculpting Play-Doh, while one tot sprawled in the middle of the floor, her socks and shoes discarded beside her. "She's just having one of those days," explained Johnson, who now has more patience. Instead of scolding the 3-year-old, as she might have done before, she talked to her and hugged her.

The elementary schools have also instituted new rituals. At the beginning of the day, for example, when students stream into Furman L. Templeton's cafeteria, Principal Debra Santos and a social worker are on lookout duty. They scan the faces for signs that someone is upset. When they notice a child who seems off-kilter or overwhelmed, they take him or her aside to see what's going on.

One morning when the University of Maryland's Mayden was at Samuel Coleridge-Taylor for a meeting, staff members brought in a boy who was sobbing. "My heart hurts," he cried. Mayden immediately worried about a serious health problem, but a social worker who knew the boy took him aside to talk. It turned out the boy's father had been arrested the previous night, and he was afraid he would never see his father again.

Once the children get to their classrooms, some teachers gather them in a circle for what they call the "daily rap." The schools, with the leadership of the Promise Heights team, started the custom three years ago as a way to let students unleash feelings and express themselves. The hope is that if something is on their minds, they will talk about it, rather than hold it in. Then they'll be better prepared to concentrate and learn.

This fall, during the daily rap in teacher Ladaisha Ballard's fifth-grade class at Furman L. Templeton, students discussed the Ebola virus. Ballard thought this might spur talk about drug addiction. She discussed whether the disease might spread easily if it ever hit Baltimore, because there are so many drug users and the virus is passed through bodily fluids. Soon the kids opened up about family members who use drugs.

Other protocols have been put in place. When children are agitated, they can go to the social worker's office, where there is a "calm down" corner with a comfy chair and cartons filled with stuffed animals and other items. The students can pull out a book or toy that they know makes them feel better. Some kids stroke the piece of velvet tacked to the wall. If they're angry, they can pop bubble wrap. One year, the kindergarten and pre-kindergarten classes used balloons and sand to make stress balls, so they each could have their own.

The goal is to help them get rid of anxiety and to focus -- and ultimately, to regulate emotions themselves.

The social workers have also worked with police to make crime-fighting less traumatizing for the children, particularly after a SWAT team showed up one afternoon to execute arrest warrants at the nearby McCulloh Homes. Mayden said the resulting situation at Samuel Coleridge-Taylor was upsetting, with teachers struggling to pull students back inside and parents who were there for pick-up trying to reach their kids.

Now the police give the school staff a heads-up on any raids, Mayden said. She's also asked officers to remove their sunglasses when talking with the children, to appear less intimidating. Such incremental changes can help reduce trauma in a neighborhood where seeing raids, arrests and even lifeless bodies on the street has become routine for children.

Shanikia Johnson, a teacher at Little Flowers, likes to be with the children outside for sunlight and exercise, which seems to help them focus.

What works

In other parts of Baltimore, there are scattered efforts to limit the impact of violence on children. Maryland's chapter of the National Alliance on Mental Illness is working to step up the role that primary care physicians play in helping people exposed to trauma in violent neighborhoods. Behavioral Health System Baltimore has funded programs to put counselors in some public schools.

Nationally, trauma-focused treatments and initiatives are being disseminated to the systems most likely to encounter these children: child welfare, pediatric and emergency rooms, courts, schools and law enforcement, in part through the National Childhood Traumatic Stress Network. The Yale Childhood Violent Trauma Center is collaborating with the International Association of Chiefs of Police to develop training for police officers responding to traumatized children during calls for service.

"While there is enormous potential for traumatized children and families to get help to recover through evidence-based treatments and program strategies, the funding to support their proliferation needs to be far greater than it currently is, given the public health crisis we face," said Dr. Steven Marans, the director of Yale's center and the Harris Professor of Child Psychiatry.

But many programs in the Promise Heights initiative have ripple effects. As adults are supported in various ways, they can support the kids. And research has shown that having a bond with an adult is a powerful way for children to overcome the consequences of violence, poverty and other social ills. Even an adult who is not a relative can offer stability.

"Attachment is critical for the child to develop self-regulation of their emotions," said Belcher, of Kennedy Krieger. "So when you get a little frustrated, you're resilient, you come back."

For Shamira, the Samuel Coleridge-Taylor fifth-grader whose sister was killed in March, the strong bond with an adult has helped balance out much of the violence around her. Brewer, the step-grandmother, has been the steadying force in her life for years. So despite what she has to deal with, Shamira is a good student who loves math. She plays teacher to her stuffed animals and chats with friends at lunch and recess. She loves her neighborhood, and someday wants to be a teacher, or maybe join the Army.

Brewer, in turn, feels she was able to support Shamira because someone was there for her: an aunt. Brewer recalls fighting and stabbings when she was growing up in Sandtown, but she stayed involved in church and found passion in sewing clothes -- and her aunt always took her aside to talk with her.

Brewer, 63, has experienced her own losses. Her son, Torrey, died at age 23 -- he was found hanging from a tree in a park. Police ruled it a suicide, but Brewer believes he was killed because he associated with an unsavory crowd. She also now helps care for the 2-year-old son of Shamira's murdered sister.

"Most kids [here] know somebody in the family who was shot or killed," Brewer said. She has a strategy for keeping her own pain in check: "I have a box in the back of my brain, and I just put everything in and close it down."

Meanwhile, she works to keep herself -- and the kids -- strong. And she helps them see the good in life. She mentors younger parents in a support program, and she's the president of the parent teacher association at Samuel Coleridge-Taylor, where she's known for her big smile and hugs. She's like a grandmother to all.

"You can't be scared. You can't shut yourself in," said Brewer, who encourages socializing and friendships among the families. She pushes parents to get their children outside to the new playground, or to enjoy snow cones from the machine she brings out on the sidewalk.

And in ways big and small, the Promise Heights team, along with teachers, day care staff and many others, have seen hard-won triumphs.

One program that teaches parents how to bond and interact with their kids -- Parent University -- has a waiting list. In one of the elementary schools, scores on a test of school readiness rose by 30 points. And in the last few years, absenteeism at Furman L. Templeton has dropped from 26 percent to 10.7 percent.

Perhaps most telling, the social workers in schools who used to have to chase the "runners" are starting to savor a new dynamic. Amanda Malone-Diel, a University of Maryland graduate student in social work who counseled students at Samuel Coleridge-Taylor, remembers following a kindergartner who ran all over the school -- to the first floor, second floor, gym, bathroom and cafeteria. Then one day, the social worker stopped chasing her and simply waited in one spot.

Gradually, the girl started to run back to her counselor. And sometimes, she wouldn't run at all. Instead, they'd sit together, one hand on chest, one hand on tummy, and breathe. There, amid all the neighborhood troubles, Malone-Diel created an oasis of quiet, a chance to take the student to a more peaceful place, if only for a few minutes.

"One, two, three, breathe," Malone-Diel said slowly. "One, two, three, breathe."

Shirley Ropka gets her son, Chuck, rear, ready for bed at her house in Parkville. Chuck has lived in the basement of the family house since he was shot and partially paralyzed 35 years ago.

PART TWO: Some WOUNDEd wind up at home - Families struggle to care for victims of violence

His mother remembers the way he used to be: a daredevil with an athletic build who drove a red Pontiac Firebird, listened to hard rock bands like Metallica and did handstands on his thumbs.

But when a neighbor waving a gun shot Charles "Chuck" Ropka in the head, the Parkville 18-year-old was left paralyzed on his left side. The shooting derailed the high school graduate's plans to study to become a diesel mechanic. Instead of seeing him move out on his own, his mother, Shirley Ropka, suddenly had to make a place to care for him in the family's basement. And that's where he still lives -- 35 years later.

"He gets mad when I say it, but it felt like I had a large baby," said Shirley Ropka, who became his medical aide while caring for three other children. "I was 41, and they always say life begins at 40. My whole life changed. I think more or less I focused on him most of the time."

She and her husband found themselves on a decades-long odyssey -- an emotional, physical and financial struggle that illustrates the unseen toll of violence in the Baltimore region.

Even in Baltimore, which has the fifth-highest murder rate among major U.S. cities, far more people survive violent attacks than die from them. Here, for example, in 2014 there have been 204 homicides and 356 nonfatal shootings. Many of these survivors spend weeks or months in rehabilitation units learning to walk, speak and eat again. Others, like Chuck Ropka, are left with permanent disabilities.

For victims who survive a serious brush with violence, a string of relatives often must pick up the pieces. They're loving moms, dads, siblings, aunts and grandmothers who are thankful their relatives survived, but who are unexpectedly thrust into the role of caretaker for someone saddled with severe physical or mental health problems. Long after the adrenaline and terror of the emergency room moments, these families shoulder a heavy burden as new caregivers.

"It can have a tremendous, traumatic impact on people's lives that affects the whole family," said Dr. Michael A. Scharf, a University of Rochester psychiatry professor who has studied the impact of violence on families.

No one knows exactly how many survivors of violence wind up disabled, but some statistics give a glimpse of the numbers: Violence is the third leading cause of spinal cord injuries in the country, affecting about 40,000 people a year. In addition, about 275,000 people suffer traumatic brain injuries caused by violence every year.

Similarly, no one knows exactly how many survivors of violence end up disabled, living with their families or in nursing facilities.

Strain on the family

In Chuck Ropka's case, the paralysis, which requires him to use a wheelchair, was accompanied by a head injury. Though caring for him was never a question for the Ropkas, who live in a modest, three-story rowhouse, the experience has at times strained the family.

Experts say there is a lack of research on families like the Ropkas, but compare their experience to that of families of injured soldiers back from war. Caregivers who tend to injured soldiers suffer from depression, isolation and financial burdens. They have a higher burden of stress, compared to more typical caregivers, for example, someone who cares for an elderly person, according to a study by the National Alliance for Caregiving. That's because they tend to be in the caregiving role for longer periods of time, and perform more daily tasks such as bathing and feeding a loved one.

"The cost goes into the millions very quickly," said Wanda Page, founder of Disabled Crime Victims Assistance Inc., a Texas nonprofit that works with families like the Ropkas. "The treatment still goes on. It's not like they are paralyzed and that is it."

The Ropkas' younger daughters remember the early years, when paramedics were summoned in the middle of the night because of their brother's seizures. The family wasn't able to go on many outings or vacations. His mother recalls the time she left him to pick up her husband from work, and her son tried to go to the bathroom on his own. He wound up tangled in the toilet, humiliated, and the Fire Department had to be called to help. For years, his mother rarely left him alone again.

His mother tries to block out thoughts about the crime -- in which the neighbor was charged but acquitted -- and its aftermath. Yet at age 76, she has had plenty of moments when she wondered why this happened to her family. Going to church, Calvary Lutheran, helped.

"I just take each day as it comes along and just deal with it," she said.

Chuck Ropka, 53, is close with his parents and appreciates how they have cared for him over the years. He, too, has learned not to dwell on his past.

"I have to live my life," said Ropka, who communicates well, but sometimes confuses memories because of his brain injury.

Today, the Ropkas must keep up with new health problems that constantly crop up. Two years ago, Chuck Ropka had all his teeth pulled because seizure medicine ate away the enamel. The paralyzed side of his body is stiff because he didn't always go to physical therapy. He lost two toes, fragile from a skin infection, when he banged them on the side of the bed. And because his limbs are so stiff, he once had to ride with his feet hanging out the window of his mother's station wagon.

The family had to reconfigure his basement bedroom with a hospital bed and other changes to fit his new life in a wheelchair. Medicaid, the federal-state health insurance program for the poor and disabled, has covered many of his medical bills. The family has turned to grants and nonprofits for more help.

But Shirley Ropka, who baby-sat children for a living, and her husband, a retired butcher, had to pay for a lot on their own. They took a nearly $15,000 loan -- more than the original cost of their house on Red Oak Road -- to widen doors and install a wheelchair lift, along with a device to help lift him. Later, Chuck Ropka's stepfather cashed in a $5,500 life insurance policy to pay for an elevator to carry him from the basement to the driveway.

In Maryland, the state program that compensates crime victims paid out nearly two-thirds of its dollar awards in fiscal year 2014 for assaults such as gunshots, stabbings and beatings. (Most of the remaining money was related to homicide cases.) Much of the money for the assault victims went for health care -- $2.7 million for medical and dental claims and $75,000 for mental health claims. About 41 percent of claims were paid to Baltimore residents. But officials with the Criminal Injuries Compensation Board note that the fund is the last resort for victims, who must first tap out private insurance and Medicaid, meaning the overall cost of caring for victims is likely much more. Ropka did not get money from the fund.

All these families must adjust to a new reality. Neurological damage can alter a person's personality, something families may struggle with, said Melanie Brown, director of Brain Injury Rehabilitation at the LifeBridge Health Brain & Spine Institute, which treats victims of violence who suffer brain injuries.

"It's like the person you knew isn't there anymore," Brown said. "They say things differently. They act differently."

The victims, in turn, also struggle. A small percentage never fully accept their new fate, turn to drugs or alcohol and even end up homeless, advocates say. Younger disabled victims sometimes wind up living in nursing homes, next to people their grandparents' age.   

Shannon L. Dudley, left, disabled since he was stabbed in the heart several years ago, is cared for by his grandmother, Nellie Ransome.

Brought back home

One Baltimore-area family watched their son deteriorate in a nursing home, so they decided to care for him at home. Shannon Dudley was 22 and attending school to become a barber when he was beaten and stabbed in the heart during a 2008 robbery at a bus stop at Charles and Baltimore streets. He emerged from a coma severely disabled and made some progress at a rehabilitation facility. But once he was sent to a nursing home, he seemed to withdraw.

Fourteen months after the injury, the family brought him back to the rowhome where he had been living with his mother. He couldn't walk and needed help being fed and bathed. Dudley's maternal grandmother, 72 and retired from work as a crossing guard, decided to care for him.

"It was my grandson," said Nellie Ransome, a petite and determined woman with the strength and energy of someone much younger. "I had to do it."

Physicians say it's hard to know which patients will recover, and which will suffer lifelong disabilities. With brain damage, the most improvement occurs within the first few months. With physical disabilities, it may take years of physical therapy to make gradual improvements. One factor is the determination of the patient. Dudley at times seems to have given up, but his family still believes he will walk again.

His grandmother arrives each morning at 6 a.m. to get him dressed. She tenderly bathes him, brushes his teeth and slides his stiff body into clothes. His 5-foot-8-inch frame towers above her 5 feet 3 inches, but she manages to lift his body and move him into an old office chair with wheels. She rolls that chair to the top of the steps and slides his body onto a glider chair, which takes him downstairs.

On a recent morning, Ransome held his head and whispered to him, praying with him. She then fed him spoonfuls of eggs, grits and applesauce.

Lately, Dudley now 29, has been feeling pain in his legs. He cries and points to his thin limbs, but can't say what is wrong. His mother and grandmother have spent long nights in the emergency room in hopes that doctors could provide some relief. And his grandmother now tries to exercise his legs each day, wrapping her arms around his chest and lifting him in the air. She then moves each leg back and forth and sways his body from side to side, as if to mimic walking, using her own version of physical therapy.

Two men were convicted in Dudley's assault. His mother, Tilithea Ransome, who commutes to Washington for her work as a pension financial manager for the city, gets angry when she thinks about that day. She believes others were involved. But she tries to focus on giving her son as normal a life as possible.

Most days, Dudley and his grandmother watch television. She steers clear of anything violent, and instead, they enjoy reruns of "Martin" and other comedies. Dudley's face lights up and he waves his hands, as his body shakes with laughter at comedian Martin Lawrence's antics.

His mother tries to keep his life as normal as possible and has even managed to take him on trips, including a recent cruise to Mexico.

Despite the obstacles, Tilithea Ransome, 53, is glad her son survived, when so many don't. It is this notion that gives her a positive outlook.

"My son lived. That was for a reason," she said. "We know he will walk one day. I will never give up hope on him."

Shirley Ropka helps her son, Chuck, take off his sweatshirt in the basement of their home in Parkville.

An unclear future

The Ropkas have also leaned on their faith. Stepfather Carl Ropka said their church has helped them cope. They are also fortunate, he said, that services for the disabled -- particularly transportation -- have improved since his stepson was hurt. An aide comes in several hours a week to take him to the movies and on outings.

His mother has gone out of her comfort zone to do things for him -- even taking him to a strip club once. She rolled his wheelchair to the front entrance, pushed him through the door and then ran off so she didn't have to go in.

Chuck Ropka, too, has adapted to life in a wheelchair. He goes out on his own several days a week, even wheeling himself to vote on Election Day. He has a "main girl" at The League For People With Disabilities, an adult day care center in Northeast Baltimore that offers rehabilitation services and recreational activities for people with severe physical or neurological disabilities. But he still gets down and frustrated at times.

"Then I just say I'm thankful to be alive," he said. "My life is good to me."

His parents, meanwhile, are getting older. Shirley Ropka needs knee surgery but postpones it because she needs to take care of her son. She goes up and down the stairs using the chair lift built for him.

And the future is unclear. The Ropkas plan to leave the house to their son, but they don't know who would care for him. Shirley Ropka tries not to think about it that much. She relies on a personal philosophy to get her through each day.

"There's always somebody worse off than you are," she said.

Each night, for all these years, Shirley Ropka goes downstairs and helps her son get ready for bed. In a kind of quiet duet, they work together -- he changes his own shirt, and she helps with the pants.

He drags his body onto the bed, and -- just as she did when he was growing up -- she pulls up the blanket and says good night. 

Alice Oaks, left, and Greta Willis weep during the Survivors Against Violence Everywhere holiday gathering.

PART THREE: HIDDEN SORROWS - Relatives of Baltimore murder victims struggle with grief

When Alice Oaks' older son was shot to death in Baltimore in 2008, she said her goodbye at the Maryland Shock Trauma Center. He lay there, a tube still in his mouth, and it seemed to her that his body was glowing. She felt numb. She bent over and kissed him softly on the forehead and the cheek.

Then, last May, driving home from a seafood dinner, she got a phone call that her other child, also a son, had been shot dead. She screamed and beat her hands on the steering wheel, so hysterical that she stopped the car in the middle of the road.

"Not my only son," she cried out over and over. "Not again."

Her words could be a refrain for Baltimore, which has the fifth-highest homicide rate of major U.S. cities. The brutal killings leave behind thousands of families who must grapple with the debilitating aftermath. Like the children exposed to violence, or the caregivers tending sons disabled by shootings, the grieving relatives of the murdered are little noticed after the funerals and the candlelight vigils. But their suffering is part of the devastating domino effect of violence in the city.

For Oaks, 61, and other relatives, the holiday season is especially painful, and the fallout from a violent death goes far beyond what most people imagine. Numerous studies show that the relatives of homicide victims suffer in a different and often more intense way than those who have lost a loved one through natural causes, or long illnesses -- partly because they must deal with the criminal justice system.

Every part of their lives is affected. Some can't hold jobs, and families break apart. Grieving parents may not realize their own children are also suffering. They often develop mental and physical health problems, including eating disorders, insomnia, depression and paranoia. They get pain in the arm or chest, where their loved one was shot. In a phenomenon known as "broken heart syndrome," intense grief can weaken the heart and lead to heart attacks. So can the anger, scientists say. In certain cases, some researchers believe, the burden of grief -- if not treated -- can kill people.

Alice Oaks’ Christmas ornament for the SAVE gathering.

Impact of homicide

In one of the largest studies ever done on the bereaved relatives of homicide victims, the findings were striking: 100 percent reported that the murder of a loved one had affected their health, 25 percent stopped working permanently, and 25 percent suddenly gained responsibility for a child. All of them suffered significant financial burdens, according to the 2011 government report from the United Kingdom, which involved interviews with more than 400 families.

"I don't want to do anything. I just want to withdraw into a cocoon," said Oaks, who experiences heart palpitations, anxiety attacks and headaches. She takes antidepressants but finds herself sometimes crying uncontrollably. Both sons had been convicted of minor drug offenses, but she felt they were working to build better lives.

Researchers estimate that every homicide has a direct impact on 10 other people, which means nearly 24,000 Baltimoreans have been affected by homicides -- just in the past decade. And that's on top of other decades of loss.

"This has been going on for 30 or 40 years if not longer. This has been two or three generations of death," said Phil Leaf, a professor and director of the Center for the Prevention of Youth Violence at the Johns Hopkins Bloomberg School of Public Health.

At the state level, there is a growing awareness of the toll. The General Assembly, noting that many areas of Maryland lacked necessary counseling and follow-up services, passed a law this year to provide funding to better support these relatives. So far, the funding has paid for police sensitivity training, more support groups and home visits from social workers.

"The old saying 'Hurt people hurt people' is so true,'" said Annette March-Grier, president of Roberta's House, a grief center in East Baltimore. "We need to address the rippling effect and the emotional scars that are left behind from violence -- because it will only replicate violence again. Anger turns to rage, and then it becomes self-destructive if that anger is not resolved in a healthy way."

City health and public health officials have long seen violence as almost an infectious disease, because of the way it can spread through the community. Two local violence prevention initiatives, Operation Ceasefire and Safe Streets, have had varying degrees of success. Still, more than 200 people have been killed in Baltimore this year.

Particularly hard hit is Baltimore's African-American community, which accounted for 90 percent of the homicide victims this year. Most of the 600 clients who use grief counseling and other services in a program at the Baltimore City state's attorney's office are African-American mothers. The problem is so severe that a sociology professor moved here in 2007 to work at the University of Maryland School of Social Work so she could study how African-Americans are affected by homicide and how to help them.

"There is a culture of homicide," said Tanya L. Sharpe, the associate professor who moved here from Boston. The survivors' grief is often mixed with the shame, blame and stigma that may surround crime, even if the loved one was an innocent victim.

It is not uncommon for mothers in Baltimore, like Oaks, to have more than one child who was murdered. A trauma surgeon at Johns Hopkins Hospital recalls walking out of the operating room last year to tell relatives that a young man, shot in the heart, had died.

An elderly woman looked at the surgeon, Dr. Adil Haider, in recognition and said, "Oh thank God, it's you again."

The woman, the grandmother of the shooting victim, explained that Haider had operated on two other grandsons who had been shot within the past year. One managed to pull through. A second, shot in the head, died. And by the look on Haider's face the third time, she knew this grandson was also dead.

Some of Baltimore's homicide victims have been involved in criminal activity. Many others are innocent victims. Either way, their deaths have an impact, Haider says. "People don't realize that behind every person who dies is a loving family, and the people who saw this child grow up," said Haider, who operated on hundreds of young male gunshot victims in his six years at Hopkins, and is now at Brigham and Women's Hospital in Boston. "There are a lot of people who love that person."

Criminal justice system

Heartbroken families must make their way through the criminal justice system, which often interferes with the way they process their grief. Funerals are delayed while autopsies are completed. People's homes are closed off as crime scenes. When killers are unknown, family members are suspects.

Even when killers are caught, trials make families relive the ordeal. Many cases are heard numerous times because of hung juries and appeals, prolonging the sorrow.

"It's like opening the wound and closing it, opening the wound and closing it," said Kim Holmes, director of the Family Bereavement Center at the Baltimore state's attorney's office, which tries to help families navigate the criminal justice system.

In the case of Oaks' first son, Irvin Lawson, 31, the killer was quickly arrested and brought to trial, eventually sentenced to life plus 20 years in prison. Knowing that the man who murdered her son was brought to justice eased some of Oaks' grief.

When her second son, Larry Henderson, 30, was killed, his body was taken to the morgue before she even learned of his death. Oaks said she wasn't allowed to see him for another two weeks -- just before he was buried.

His body was found in the Westport area of South Baltimore. Six months later, no one has been charged.

Today, the two brothers are buried side by side, and the combination of losing a second son and not knowing the killer has made Oaks' sadness almost debilitating, she said. Even though she runs a support group for survivors like herself -- called Survivors Against Violence Everywhere -- she often feels isolated, as if no one understands. Even Oaks' husband once asked her why she hadn't gotten over one of the sons' deaths.

Relatives report feeling stigmatized and judged because of the way their loved ones died. People would insinuate that the victims were to blame, according to research published in June from York College in Pennsylvania. That may cause survivors to lie about the death and afterward feel guilty for not being true to the victim, according to the research. One survivor said that after telling a co-worker about her son's death: "I could tell she was judging me and judging my son, and that hurt. I thought, 'Why the hell did I put myself out there?' "

Other survivors find that close friends become uncomfortable, and rather than say something wrong, they say nothing. One woman told researchers she wanted to put a big sign on her forehead that said, "Talk to me please." 

Toll on health

Dealing with the ups and downs can take a toll on relatives' emotional and physical health.

It took Nichole Parrish months before she finally faced the death of her mother, who worked in the bail bonds business. The Baltimore woman, 42, was shot in the chest in the fall of 2011 by a client who left her bleeding in a Columbia parking lot.

Parrish's breaking point came during the trial, when she saw her mother and namesake, Nichole Bernadette McNair, limp and lifeless in the autopsy pictures. She tried to walk out of the courtroom but was frozen in place and found herself sobbing uncontrollably.

The killer was convicted, but it was the beginning of a downward emotional spiral for Parrish. She suffered panic attacks and didn't sleep for days at a time. The University of Maryland, Baltimore County student stopped going to a job she had just started, working with children with autism, and missed some days of class. When the semester ended, she had no reason to get out of bed at all.

Parrish's condition got so bad that she was admitted to Johns Hopkins Hospital for three months. She was diagnosed with post-traumatic stress disorder, a trauma-induced disorder often found in soldiers who come back from war, but now more commonly diagnosed in people who experience other tragic events.

Parrish, 23, has since graduated from UMBC, found a job in customer service and lives with her father in East Baltimore -- but deals with her mother's death every day. She finds herself crying at work sometimes. She has recurring nightmares of her mother getting shot in different places around town. And the panic attacks recur.

"I get really scared," said Parrish. "I just get panicked that something is going to happen. Then I wonder if something happens, 'Where will I go? What will I do?' "

Research shows that Parrish's experience is common among the relatives of homicide victims.

Before leaving for college, Nichole Parrish posed for a photo with her mother, Nichole McNair, who was shot and killed in 2011.

In the York College study, Jeanna M. Mastrocinque, an assistant professor of criminal justice, and her colleagues conducted focus groups with nearly 30 relatives in Rochester and Albany, N.Y., and parts of Indiana. They found that anxiety and paranoia took over the lives of some relatives. They adopted quirks to help them feel safer, including switching to a sheer shower curtain to see intruders, sleeping with the lights on or always keeping the blinds closed. For those notified of the death by someone who came to the house, or called, a knock on the door or ring of the phone triggered anxiety attacks.

Scientists at Johns Hopkins and other institutions have found that grief can cause biological changes. The immediate grief after a death can weaken the heart and increase the risk of heart attacks. The lingering anger associated with this grief can also cause heart problems, a Harvard University study found. Other research connects intense grief to high levels of stress hormones, a weakened immune system and trouble sleeping.

Relatives interviewed in Mastrocinque's study attributed illnesses such as cancer, heart attacks and death to their grief. Many complained of feeling physically sick, and some lost so much weight that they dropped three or four clothes sizes. One described it this way: "I think this has changed me on a molecular level."

Mastrocinque's study recommended that primary care physicians pay more attention to the health status of the relatives of the murdered, given all the problems they reported.

"Homicide is one of the leading causes of death for many age groups," Mastrocinque said. "I don't think people think about how much homicide ripples through communities."

Michelle Randolph considered herself fairly healthy before her only child, Wesley Lewis, 19, was found murdered in August 2010. After his death, the Baltimore woman couldn't control her blood pressure and suffered from panic attacks and depression. "My chest tightens and my heart starts to work [hard]. It's like it's flooded," she said. "They say it's just stress."

Many health problems can last months after the initial grief, a study by researchers at the University of Wisconsin-Milwaukee School of Nursing found.   

Nichole Parrish helps her half-brother, Noah Parrish, 4, with his school uniform before heading to school. Isaac Parrish, 6, is another half brother. Nichole Parrish has struggled with post traumatic syndrome since her mother’s killing.

Grief kills

Within the circle of victims' relatives she knows, Oaks believes she has seen grief kill. She remembers a mother who never seemed to get over her child's death, who suffered from depression, then a stroke and ended up in a wheelchair. A few years ago, she died in a bathroom during a birthday party.

In her work, Sharpe, of the University of Maryland, has interviewed 300 people in several cities, including more than 80 in Baltimore. She found that, on average, African-Americans nationwide have experienced the homicide of a loved one at least 2.5 times in their lifetimes -- much more than other groups. Yet African-Americans are often neglected in research about this issue, something Sharpe is trying to address in her work.

She discovered that African-American families often suppressed their feelings, either because of the stigma of being associated with such a horrific crime, or to deal with everyday life, such as working and putting food on the table.

"The way we deal with grief and loss as a people is to suck it up, move on and deal with it, and pretend as if nothing has happened. That has been our culture -- the African-American culture -- to not show emotions," said March-Grier of Roberta's House.

Gaining the trust and drawing out feelings of her clients, many who are African-American, can be difficult, she added.

Recently, Roberta's House got funding from the new state legislation to enhance its grief services, to help make recovery less difficult for African-American survivors and figure out ways to help them. At an evening session last week, tears flowed as the relatives shared their stories. One mother blamed herself for not doing enough to protect her son, while another talked about being angry at God for allowing the killing. Others talked about the rise and fall of emotions that made it hard to get out of bed.

Other grassroots support groups have formed to help survivors. Activist Millie Brown started A Mother's Cry in 2007 after seeing traumatized families at Johns Hopkins Hospital, where she cleaned operating rooms. She discovered that 50 fellow employees had relatives who had been murdered. Now she tries to tell survivors they need to live, even if their kids didn't.

"The pain never goes away," Brown said. "I am there to give them something better. The only thing I want is to see them smile and to see them laugh."   

The burden of holidays

This week, around the holiday season, much of the hurt intensifies.

Oaks isn't sure what she'll do on Christmas. Her brother is trying to persuade her she shouldn't be alone.

Parrish, who lost her mother, also agonizes from day to day about whether to spend the holiday with family or not.

Randolph can't stand to be around people who have their families when she no longer has hers. So she'll spend the day by herself and light a single candle for her son.

Some bereaved relatives find solace in an annual ceremony that helps them honor their loved ones. Started several years ago by Survivors Against Violence Everywhere, the ritual was held this month on a chilly, rainy evening at City Hall. Even the band that was playing at the event had been affected by homicide -- three of the musicians had lost relatives to violence.

As a member of the group read the names of those who had died, family members came up, one by one, to hang an ornament on a tree. Most of them were mothers, and many of the ornaments were adorned with the names and pictures of the victims. They cried and hugged each other. Oaks sat in the front row, dabbing her eyes, rocking back and forth with another mother.

It didn't bring back their loved ones. But for at least a night, it let them remember they weren't alone.